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Page | 1 Skills for Wellbeing Course Welcome pack
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Skills for Wellbeing Course
Welcome pack
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Contents
Useful information:
Risk information
Attendance policy
Confidentiality policy
Session 1: Introduction to the course and Cognitive Behavioural Therapy
(CBT)
Session 2: Introduction to depression and strategies to manage low
mood.
Session 3: Introduction to anxiety, Worry Management strategies and
Problem solving.
Session 4: Addressing unhelpful depressive thoughts and thought
challenging.
Session 5: Panic Management and Relaxation techniques.
Session 6: Improving sleep and looking after yourself in the future
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Useful Information
Risk
It’s very common when we feel low or anxious to have thoughts that we would be
better off dead or of wanting to harm ourselves in some way. Even though these
thoughts are common we take this very seriously and want to do our best to ensure
everyone on the course is safe. While having these thoughts is normal, if they
progress into plans or intent to harm yourself in any way, there are people you can
talk to.
Please approach one of the course facilitators before or after the session and they
will be able to offer support. However, if you are experiencing these thoughts in
between sessions then here are some safety plan options.
Visit your GP - If you contact your GP and explain that you are having these
thoughts they will fit you in for a same day appointment either in person or on the
telephone.
Local Accident and Emergency Departments - There are crisis teams in the local
A&E departments who will offer support. They are located at:
Samaritans – 116 123
Samaritans is a registered charity aimed at providing emotional support to anyone in
distress or struggling to cope in the UK. You can contact this number any time of the
day or night and your involvement with this service is kept strictly confidential
The Royal Liverpool Hospital
Prescot Street
Liverpool
L7 8XP
Aintree University Hospital
Lower Lane
Liverpool
L9 7AL
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Attendance Policy
Welcome to Talk Liverpool. We want to offer the best service we can. To do this, we aim to keep our waiting lists as short as possible. Because our service is very busy, we have a policy about missed appointments that we ask you to agree to and sign before starting course treatment with us. Coming to all your appointments also greatly increases your chances of feeling better! Over 80% of people who complete our courses make a full recovery from their problems! (Talk Liverpool October 2017) Please read the information below carefully before signing. Your course leaders will be happy to answer any questions you may have. MISSED APPOINTMENTS POLICY If you need to cancel your course session, please give at least 48 hours notice. If you miss two sessions during the course, we will discharge you from the service. This includes contacting the service after your appointment time has passed. Please note that if you arrive more than 20 minutes late for your course session, you may not be able to join the session. If you arrive 20 minutes late on two occasions, you may be discharged from the service. If, during treatment with us, you change your GP so you are no longer registered with a GP in the Liverpool area, we will be unable to offer you a service at the end of your current course of treatment. Any more treatment must be given by the talking therapy service in your new GP area. I agree to the above policy. Name: Date: Thank you for agreeing to our missed appointments policy - we look forward to welcoming you into Talk Liverpool.
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Confidentiality Policy What you speak about to your course facilitator is confidential within the service and, if you were referred by your GP or another health professional, your GP/referrer. If you self-referred, we would need to let your GP know if we were concerned for your safety or the safety of others. At the beginning of the course, we ask all course members to agree to keep private the information shared by others on the course. The only times Talk Liverpool would need to break confidentiality is if we felt, at any time, that you or someone else was at risk from harm and then we would have a duty to pass that information on. We also have a duty to tell someone, for example, about suspected acts of terrorism, or about any risks to children or vulnerable adults, and this includes information about things that have happened in the past. If we do need to break confidentiality, we would attempt to let you know before doing so. Storing your information: We comply with the Data Protection Act, which means any personal details about you, and any clinical notes we make about your sessions, are kept private and recorded securely on our systems. We might use data for monitoring purposes (such as information we collect on gender, age, ethnicity etc.,) but this is anonymous and no one will be able to link any of the information back to you. Please note that case notes can be requested as part of a court case or legal issues. For more information about Talk Liverpool, please visit our website: www.talkliverpool.nhs.uk. To contact our main office, telephone 0151 228 2300.
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Session #1
Introduction to the course and
Cognitive Behavioural Therapy (CBT)
Welcome and Introduction to group structure
The Skills for Wellbeing Course is underpinned by Cognitive Behavioural Therapy
(CBT), the main aim of the group is to improve mood and reduce stress and anxiety.
The 6 Sessions will consist of a mixture of theory and practical exercises, these will
last around 1 ½ - 2 hours. You are not expected to share personal experiences in the
group however it is important that you complete the out of session work and that you
bring your workbooks to each session as we will be referring to it frequently. We will
have a break mid-way through each session giving you time to speak to group
facilitators if necessary. Please remember this is not group counselling.
At each session, we’ll help you to:
– Understand the information given.
– Plan how to practice the exercises.
– Review what you’ve learnt from the exercises.
Outside of each session, you are responsible for doing the exercises. This is known
as the ‘Plan, Do, and Review’ approach
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Cognitive Behavioural Therapy (CBT)
National guidelines say that people with Low Mood, Anxiety or Panic should be
offered a guided self-help programme such as this. This guided self-help course is
based on a therapy called Cognitive Behavioural Therapy, or CBT for short.
Although we cannot change the life experiences we go through which may have lead
us to feeling in a certain way, we can influence how we think, feel and behave as a
result of these situations. This is why CBT focuses on current symptoms rather than
the triggers or experiences which may have contributed to our Low Mood, Anxiety or
Panic.
CBT is based on the idea that our thoughts, feelings, physical reactions and
behaviours all influence each other and we can often become trapped in a Vicious
Cycle. This course aims to break the links in the Vicious Cycle by helping you build
up your ‘tool kit’ though various skills and techniques to help you manage your
mood.
CBT Vicious Cycle:
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Example Cycle: Depression
Example Cycle: Anxiety
Example Cycle: Panic
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Setting Goals
Before we can continue and focus on the techniques to help you manage how you
currently feel, we need to think about goals. If you do not have any goals, how will
you know what techniques to use to help you move forward?
Goal directed behaviour will enable you to feel like you are living a meaningful life. It
will also help you feel good about yourself and give you a sense of achievement.
However, it is important that the goals you set are SMART.
Examples of goals which are NOT SMART:
I would like to feel happy again
I would like to feel less anxious
I would like to do more of what I used to do
An example of a SMART goal would be:
To go for a 15 minute walk twice this week.
This goal is specific and relevant to me and depending on fitness levels it should be
achievable. The goal has a time limit and is measurable as you can check in at the
end of the week to see if it’s complete.
Specific
Measurable
Achievable
Relevant
Time-limited
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Home Task 2: Using the table below, set yourself 3 SMART goals that you want
to achieve over the duration of the course.
My Goal Is it SMART? Check-List Plan of action
1.
Specific
Measureable
Achievable
Relevant
Time-limited
2.
Specific
Measureable
Achievable
Relevant
Time-limited
3.
Specific
Measureable
Achievable
Relevant
Time-limited
Tips for setting goals
Ask yourself…
What do you hope to gain?
What do you hope to have achieved?
What will be different for you?
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Session #2
Introduction to Depression &
Strategies to manage Low Mood
Introduction to Depression
Depression is a common mental health problem that involves sadness or loss of
enjoyment. At least 1 in 10 people experience Depression at sometime in their life.
Everyone feels low sometimes but with Depression, people feel low nearly all the
time for weeks, months, or years.
Depression can:
• Affect sleep, appetite, concentration and energy.
• Make us struggle to keep up with our normal daily routine.
• Make us feel worthless and make the future look hopeless.
• Make us feel so bad that we don’t want to keep living anymore.
When we feel pressed down by our situation we can start to feel hopeless &
overwhelmed by our daily activities. This can lead us to withdraw from our planned
routine or use other coping behaviours to try and avoid our negative feelings, e.g.
• If we feel exhausted we might go back to bed.
• If we feel overwhelmed, we might avoid situations.
• If we are afraid of letting people down, we might rush around trying
to please everyone.
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Behavioural Activation Technique
When people are depressed, they tend to feel as though they are stuck and not
moving forward in life. This means that we stop doing those activities we need to
such as paying bills or those that we find enjoyable such as seeing friends.
In the short-term, this may be helpful, and make us feel slightly better at the time, but
in the longer-term, it becomes more difficult to get back to doing these activities and
we do even less. This avoidance only serves to maintain feelings of low
mood/anxiety, as we are not giving ourselves the opportunity to learn that we can
cope and that things do not turn out as bad as we thought they would. We also miss
out on potentially rewarding and enjoyable experiences which may have lifted our
mood.
The avoidance of doing things we used to do before feeling down is the most
important thing to tackle when overcoming Depression. If we think back to our CBT
cycle of Depression (see image below), we look to break this cycle by focusing on
our behaviours and start gradually introducing activities back into our lives. This
technique is called Behavioural Activation.
Examples of things which people start to avoid as a result of low mood/anxiety:
1. Routine activities – house work, washing up, ironing, cooking.
2. Pleasurable activities – going out with friends/family, hobbies.
3. Necessary activities – paying bills, sorting through paperwork, sorting mail.
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Task 1: Think about the routine/pleasurable/necessary activities you have stopped
doing since experiencing low mood/depression.
List some routine activities here: e.g. washing up, cleaning the house, showering
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………...............………...............………...............………..........
List some pleasurable activities here: e.g. reading, seeing friends, cinema, playing
Xbox
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………...............………………………………….........................
List some necessary activities here: e.g. paying bills, sorting through mail
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………...............………………………………….........................
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Home Task: Think about the activities you have noted on page 14. Think about how
difficult it would be to re-introduce these activities back into your life. Use the
hierarchy below to organise your list:
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Tips on Dairy Planning
Add tasks to your diary which are balanced and realistic with your
mood level.
For the first week, just plan two or three things which you feel are
easier to re-introduce.
Keep to the plan rather than following how you feel – the negative
thoughts and physical symptoms can take you off course!
Spread the tasks throughout the week.
Break down tasks if necessary.
Try to plan when you will get up and out of bed, go to bed and meal
times during the day to establish a routine.
Set a time rather than a task.
Display your diary somewhere as a visual reminder.
Stop when you still have enough energy left to do the same amount
of what you have just done again; even if the task is not completed.
We don’t want to overdo it.
Try and think of potential barriers that could get in the way of you
completing tasks as you may have to find a way around them.
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Session #3
Introduction to Anxiety & Worry,
Worry Management strategies and Problem solving.
Introduction to Anxiety & Worry
Anxiety = An emotion that happens to all of us if we sense danger.
Immediate danger = Anxiety prompts us take action straight away (e.g.
crossing road & car speeding toward us – fight or flight)
Future danger = Anxiety prompts us to try and solve the problem before taking
action (e.g. learning that you might soon be made redundant).
Worry = anxiously thinking how we would cope with future danger that may or may
not happen.
Fight, Flight or Freeze
When faced with a life-threatening danger, it often makes sense to run away (flight)
or, if that is not possible, to fight. This fight, flight or freeze response is an automatic
survival mechanism to prepare the body to take these actions. All of the body
sensations produced are happening for good reason - to get the body ready to run
away or fight (or freeze in the presence of a threat). These symptoms may feel
uncomfortable, particularly if we don’t know why they are occurring.
If we consider some of the changes in our body that the Fight/Flight/Freeze response
creates, they may sound familiar. This response is very useful when there is an
actual danger present.
Anxiety/Worry can also trigger the physical (fight/flight/freeze) response when we
perceive a threat, but there is no actual danger present. E.g. “what if I’m late for my
appointment?” or “what if somebody I love gets hurt?” etc. can cause the fear
response (which can create further problems in the long run).
That is why if we tackle the worries, we can help to reduce and manage the physical
symptoms.
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Difficulties with Worry
While worrying and feeling nervous is something that all human beings experience,
as with many things in life, too much of something may not be good for you.
Normal anxiety can become a problem when it is:
Excessive, Uncontrollable, Intrusive in your life and Persistent – seeming to
always be around and causes you significant distress, or impairs your ability to go
about your day-to-day life.
Different types of worry
There are two different types of Worry. What we call Healthy Worry and Unhealthy
Worry, these needed to be dealt with differently. The diagrams below explain the
differences between the two.
Healthy Worry
If we are worrying about
current problems we can use a
skill called Problem Solving to
help our Anxiety and get rid of
the worry.
This is also referred to as
Current/Practical Worry (P)
Unhealthy Worry
As there is no exit point to
the worry, the Anxiety is
maintained. We can not
control a hypothetical
situation; therefore problem
solving would not work for
Unhealthy Worry. We would
use Worry Time.
This is also referred to as a
Hypothetical Worry (H)
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Dealing with Worry
It is important to recognise when a worrying thought pops into our head.
Learn your tell-tale signs of worry, e.g.
– “What if” thoughts, or mental images
– Anxiety, tension, or other physical sensations
– “Going round in circles” for more than 2 minutes
Worry Time
To help deal with Worry we use a technique called Worry Time. Through this
technique we learn it is possible to control worry. This makes worry planned, instead
of driven by emotion and starts to break the link between daily activities and worry.
Create a period in the day which is set aside for worrying.
Choose a particular time of the day that you can use for this, e.g. 5pm, before making tea.
Make this a comfortable time of day, free from distraction and at a convenient time.
Allow a set amount of time to go through your worries e.g. 30 minutes
Record your worry & postpone it.
As soon as you become aware of a worry, postpone it to the worry period.
Note your worry briefly on paper (in a couple of words only). Carrying a small notebook with you may be useful.
Remind yourself that you will have time to think about it later, no need to worry about it now.
Turn your focus to the present moment and the activities of the day to help let go of the worry until the worry period has arrived.
Come back to your worries at the designated worry period.
Only worry about the things you have noted if you feel you must.
Transfer the worries you have noted down into a Worry Diary (pg. 21).
If all or some of the worries you wrote down are no longer bothering you or no longer seem relevant, then no further action is required.
If you do need to worry about some of them, spend no longer than the set amount of time you specified for your worry period. Reflect how it feels to worry.
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Worry Diary: In your Worry Time, transfer your worries into this Worry Diary, use the
Worry Tree on page 22 to help you classify your worries into Hypothetical or
Practical worries.
Date:
Your Worry: E.g.…. What if…..
How anxious do you feel on a 0-10 scale: 0= not at all 10 = most anxious
Classify: Decide whether this is a hypothetical worry (H) or a practical problem (P)
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The Worry Tree is a useful tool to use during Worry Time. It will help you to
categorise your worries into Healthy and Unhealthy worry and therefore help you
recognise what technique to use to tackle the Worry.
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Problem Solving our Current Problems:
When we worry our problems can feel overwhelming, like there are no solutions.
Problem solving is an evidence based intervention that helps you distance yourself
from your worries to help you think about different practical solutions.
Problem solving is a technique which can be used to deal with any Practical Worries
you identify in your worry time.
Below is a 7 step framework which can be applied to everyday dilemmas/problems
we encounter which can contribute to anxiety and/or low mood.
Step 1- Identify the problem.
Step 2- Identify the possible solutions.
Step 3- Weigh Up pros and cons of each solution.
Step 4- Select a solution.
Step 5- Make a plan to put your solution in place.
Step 6- Put your plan into action.
Step 7- Review how your plan went
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Example of using the 7 step framework for problem solving.
STEP 1: Identify your problem Write down the practical worry you want to try and solve
The car is making a knocking sound, what if it breaks down or I have an accident?
STEP 2: Identify the possible solutions Don’t reject anything at this stage, no matter how silly it may seem!
- Ignore the noise, it might go away -Get the bus everywhere instead - Take the car to be fixed - Sell the car, buy a new one
STEP 3: Weigh up pro’s and con’s of each solution
Ignore noise: Strengths: none Weaknesses: Noise will keep worrying me, won’t find out if there is something wrong, it might get worse
Take car to be fixed: Strengths: They will know what the problem is and be able to advise Weaknesses: Might cost money, what if I can’t afford it?
Sell car, buy a new one: Strengths: No noise, new car Weaknesses: Cant afford this
Get the bus everywhere: Strengths: Wont need to use car Weaknesses: Time consuming, unreliable, expensive
STEP 4: Select a solution Review strengths and weaknesses to find best solution
Take the car to a garage to be fixed.
STEP 5: Make a plan to put solution into place Consider what steps you will need to take
- Research garages, find contact number - Call them during lunch break on Monday - Arrange to take car in for one day when not in work/after work - Ask for details on what is wrong with the car and get a written price quote
STEP 6: Put plan into action Keep a record of exactly what you did.
Called garage on lunch break as planned. Made an appointment to bring the car in. On the phone the garage asked questions and told me it sounded like the exhaust, reassuring me that this was an easy job and quite cheapish. I then dropped car off at agreed time and the mechanics fixed the exhaust there and then.
STEP 7: Review how it went Review how the plan went. Was there any challenges? How did you over
come this?
Went really well, felt more in control of situation. Car was fixed and did not cost too much. Was no longer worrying about this once I had made a plan of action.
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Task: Complete the Problem Solving Worksheet
Step 1 - Identify the problem
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
Step 2 - Identify the possible solutions
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
………..……………………………………………………………………………………….
Step 3 - Weigh up pros and cons of each solution
Solution Pros (strengths) Cons (weaknesses)
1.
2.
3.
4.
5.
6.
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Step 4 - Select a solution
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
………………………………………………..…………………………………………………
Step 5 - Make a plan to put your solution in place
…………………………………………………………………………………………………
…………………………………………………………………………………………………
………………………………………………………………………………………………….
………………………………………………………………………………………………….
………………………………………………………………………………………………….
………………………………………………………………………………………………….
………………………………………………………………………………………………..…
……………..……………………………………………………………………………………
Step 6 - Put your plan into action
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
……………………………………………………………..……………………………………
……………………………………………………………..……………………………………
……………………………………………………………..……………………………………
Step 7 - Review how your plan went
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
………………..…………………………………………………………………………………
………………..…………………………………………………………………………………
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Session #4
Addressing Unhelpful Depressive Thoughts
and Thought Challenging.
Unhelpful Depressive Thoughts
People who are depressed tend to think about themselves, the world and the future
in a negative way. As discussed earlier, these thoughts can influence our feelings
and behaviours and vice versa. This is why it is important to begin to recognise and
challenge unhelpful thinking. If we think back to our CBT cycle of Depression (see
image below), we look to break this cycle by focusing on our thoughts and start
challenging them through a technique called Cognitive Restructuring.
Everyone has these thoughts, these negative thoughts are:
• Automatic – They just come to your mind without any effort.
• Distorted – they are not always supported by things you know to be true
(facts)
• Unhelpful – They keep you feeling depressed and make it difficult to change
• Plausible – You accept them as facts and do not question them
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We refer to these as “Negative Automatic Thoughts” (NATs) – the more depressed
you become the more you believe these thoughts – which feeds into the vicious
cycle.
When catching your NATs you may find that there is a pattern to your negative
thinking. We call these thought distortions. A number of these are described below:
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Individual Task:
Think about the last week and identify when you have used one of these unhelpful thinking styles. Make a note of the situation you were in. Identify your thoughts that linked with the thinking style. Identify your feelings and behaviours:
Situation Thoughts (and thinking style)
Feelings and behaviour
Start to recognise your unhelpful thinking styles over the upcoming weeks.
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Cognitive Restructuring
Cognitive Restructuring is a way of changing unhelpful thoughts (which act to
powerfully maintain our mood) by identifying, examining and challenging them. It’s
important to start doing this as changing or relating to our thoughts differently can
profoundly change how we feel and behave.
Stage 1 -
Identification
of thoughts
• Complete the first 3 parts of “My thoughts diary” – identify situation, emotion and thoughts (see pg. 33).
• Rate the strength of the emotion on a scale from 0-10.
• Rate how much you believe the thought out of 100%
Stage 2-
Looking for Evidence
• Identify a thought to work on
• Refer to “Evidence recording sheet” pg. 34
• Examine the evidence for & against (just like in a court!). Courts deal with facts not opinions.
• Refer to “tips for gathering evidence for and against your thought” pg. 35
Stage 3 -
Revised
Thought
• Complete section 4 and 5 of “My Thoughts diary” (see pg. 33).
• Revise your thought based on the evidence.
• Rate how much you believe this thought.
• Notice if thinking about the new thought changes the way you feel.
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Examples of Thought Challenging – Step by step:
Step 1: Identification of thoughts
Step 2: Looking for evidence
Step 3: Revised thought
Page | 33
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Page | 34
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Page | 35
Tips for gathering evidence for and against your thought:
Start with evidence that supports your thought. Then move on to
gather evidence against the thought.
Put the thought on trial, what evidence for and against it is there
that would stand up in a in court of law?
Is this evidence fact or opinion?
What would other witnesses (e.g. friends, family colleagues) in
your life say when asked to give evidence against the thought?
Do I believe the thought 100% all of the time?
If I believe the thought 80% for example, what makes up the other
20% that doesn’t believe it?
Would I believe this thought if I wasn’t feeling this way?
Is there a more balanced way of looking at things? Are there any
other ways that I could look at the situation?
What would I say to a friend in the same situation?
Will this thought matter in five years time?
Is this way of thinking helping me to achieve my goals?
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Session #5
Understanding and dealing with Panic;
Breathing and relaxation techniques
Understanding Panic
Everyone knows what panic is, and it is common to feel panicky from time to time in
certain situations (e.g. you’re crossing a road and a car nearly hits you/ you hear an
unexpected noise downstairs in the middle of the night).
A panic attack is a bit like ‘normal’ panic but different in a number of ways:
The feelings are a lot stronger
The feelings seem to come ‘out of the blue’ and are not usually related to the
sort of frightening situation described above
The feelings often last longer than a few minutes
As the feelings are unexpected, strong and often very physical they can feel
extremely frightening. However, these feelings are a normal bodily response to a
perceived threat.
During a Panic attack, the normal physical sensations of anxiety are experienced as
dangerous and can cause people to feel that something more serious is happening,
such as a heart attack. This is what we call ‘catastrophic misinterpretations of
symptoms’.
Naturally, nobody wants to experience these panic attacks, so we start to avoid the
situations where they might occur. We begin to “fear the fear” – meaning we are
scared about experiencing the panic attack. Avoiding or escaping the situation
makes you feel better in the short term, but in the long term this avoidance is actually
reinforcing your anxiety. That is because you are learning that avoiding or escaping
the situation reduces your anxiety, which is encouraging you to be afraid of the
situation.
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Fight, Flight or Freeze
As mentioned earlier in this workbook, the body’s automatic survival mechanism is
called the Fight, Flight or Freeze response, and it is responsible for detecting and
preparing us to face danger. This fear response creates changes in our bodies which
get us ready to fight, run away from or freeze in the presence of a threat.
If we look at some of the changes in our body that the fight/flight/freeze response
creates, they may sound familiar. Although these are useful when there is actual
danger, during an episode of anxiety they are not always helpful, and in the long run
can create more problems.
Task: Below is a stencil of a body. Try to think of the symptoms that you experience
when this response is triggered, and label them on the relevant parts of the body:
:
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Below is a diagram of the body, labelled are some of the bodily changes caused by
the Fight, Flight or Freeze response:
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Overcoming Anxiety through Exposure Therapy
Exposure can be summed up as facing your fears. It involves doing the opposite of
avoidance - putting yourself in an anxiety provoking situation, experiencing the
discomfort, and learning (through experience) that anxiety, although uncomfortable,
cannot harm or damage you.
Principles of exposure therapy:
1. Graded – Start with things that make you less anxious than others and
gradually work your way onto more difficult things.
2. Prolonged – you should stay in the situation until you feel anxiety start to
subside, preferably by as much as 50%
3. Repeated – you need to have repeatedly expose yourself to feared situations
and feelings of anxiety
4. Without distraction – allowing yourself to learn that anxiety naturally
subsides over time. Not engaging in any physical and/or mental activities
which you attribute to keeping you safe – removing safety behaviours (see
below).
Safety Behaviours:
Safety behaviours relate to everything we do in order to prevent a Panic attack from happening.
Can include a wide range of behaviours which, at times, can be difficult to identify because they become part of our everyday routine. E.g. carrying water, carrying medication, making sure your phone is always charged and with you (just in case), avoiding coffee totally (or other caffeine), not exercising etc.
Unfortunately, while safety behaviours can lead to a feeling of relief in the short term (and are thus reinforced), they have the effects of reinforcing beliefs about the perceived threat in the long term.
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Example: Below is an example of a completed Graded Exposure Hierarchy:
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Task: If you are avoiding something as a result of anxiety then complete your own
Exposure Hierarchy. Start at the bottom and work your way up the ladder by facing
the situation until your fear reduces by 50% and repeat this until you no longer feel
anxious. Then you can move on to the next step. Use the Exposure Diary on pg. 42
to help to plan the activities.
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Relaxation & Breathing Techniques
The threat system responds best to messages from the body:
Relaxed breathing
Muscle relaxation
Why is Relaxation helpful?
When you are tense you will experience uncomfortable feelings such as
headaches, backaches and so on
The aches and pains of tension can add to your mental worry
Relaxing slows down the systems in the body that speed up when you get
anxious.
If you can learn to relax you will be able to cope better with the strains and
stresses of life, and also enjoy a better quality of life.
Here are a few techniques that you can practice to help you to relax.
Breathing
We have to learn how to breathe. It may sound strange because we breathe every
day without even being aware of it. Why do we need to learn how to breathe?
Well, even though you breathe every minute of every day, there is a specific way to
breathe. Do the following test to see how you breathe.
Lie down for a few minutes.
Place one hand on your stomach and one hand on your chest.
As you breathe, try to notice which hand is moving the most.
Keep still while you are doing this, and try not to change your breathing in any way.
Which hand was moving the most, the one on your chest or the one on your
stomach? If it was the one on your chest, your breathing is NOT diaphragmatic. For
correct breathing your stomach should move slightly more than your chest.
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Exercises to practice
Deep breathing
1. Take complete breaths in which every part of the lungs is filled with air.
2. Breathe in slowly and deeply, pause for a moment, and then let the breath out
slowly.
3. After a moment’s pause, repeat this.
4. Do this several times, and be sure to do it as slowly as possible.
Rhythmic breathing
1. Put your hands on your stomach, with fingertips touching, and practice slow,
rhythmical breathing.
2. Breathe in through the nose, counting to six, then breathe out counting to six
(count in your head).
3. This slow rhythm of about five breaths to the minute, instead of the usual
twelve or so will help the body to relax.
4. As you breathe in and out rhythmically, you will notice your fingertips moving
apart and coming together again, demonstrating the expansion and
contraction of the diaphragm.
5. Again, do this exercise for only a few minutes, say about five minutes. (if your
fingertips do not move apart, perform the ‘Diaphragmatic Breathing’
exercises)
Diaphragmatic breathing
Place one hand on your stomach and one hand on your chest.
Breathe slowly and regularly for a few minutes.
Gradually try to get the hand on your stomach to move a bit more than the hand on
your chest.
It may seem to strain some muscles a little at first, but this is natural since the
diaphragm may not have been exercised properly, and you are now trying to make it
do its part. Do this exercise for a few minutes daily whenever you get the
opportunity, until you are sure your breathing is ‘diaphragmatic’.
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Progressive Muscle Relaxation
Sit in a comfortable chair (or lie on the floor or on a bed). Ensure you will not be
disturbed by other noises. If you become aware of sounds - just try to ignore them
and let them leave your mind just as soon as they enter. Make sure the whole of
your body is comfortably supported - including your arms, head and feet. (Rest your
arms on the arms of the chair, with your feet flat on the floor - if sitting!)
Close your eyes. Feel the chair supporting your whole body - your legs, your arms,
and your head. If you can feel any tension, begin to let it go. Take 2 slow and deep
breaths, and let the tension begin to flow out.
Become aware of your head - notice how your forehead feels. Let any tension go
and feel your forehead become smooth and wide. Let any tension go from around
your eyes, your mouth, your cheeks and your jaw. Let your teeth part slightly and
feel the tension go.
Now focus on your neck - let the chair take the weight of your head and feel your
neck relax. Now your head is feeling heavy and floppy. Let your shoulders lower
gently down. Your shoulders are wider, your neck is longer.
Notice how your body feels as you begin to relax.
Be aware of your arms and your hands. Let them sink down into the chair. Now
they are feeling heavy and limp.
Think about your back - from your neck to your hips. Let the tension go and feel
yourself sinking down into the chair. Let your hips, your legs and your feet relax and
roll outwards. Notice the feeling of relaxation taking over.
Notice your breathing - your abdomen gently rising and falling as you breathe. Let
your next breath be a little deeper, a little slower...
Now, you are feeling completely relaxed and heavy. …. Lie still and concentrate on
slow, rhythmic breathing….
When you want to, count back from 5 to 1 and open your eyes. Wiggle your fingers
and toes, breathe deeply and stretch. Look around the room, becoming more alert as
you notice what you see, hear and feel. Pause before gently rising.
© Carol Vivyan 2009, permission to use for therapy purpose
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Session #6
Improving sleep and
Looking after yourself in the future
Why is sleep important?
Getting a good night’s sleep is vital for us because:
• It helps young ones grow
• It repairs our tired bodies
• It sorts out our thoughts and memories
• It boosts our wellbeing and fights infection
During sleep our body typically goes through numerous sleep cycles. Each cycle
consists of 5 stages of sleep as shown in the diagram below.
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Stages of Sleep
Stage 1: is your transition from awake to asleep, the point where you’re not quite
awake but not fully asleep either.
Stage 2: is called ‘True Sleep’ you are now asleep but it’s not yet deep sleep so you
can be quite easily woken.
Stages 3+4: are ‘Deep Sleep’ it can take about half an hour to get to your deepest
point of sleep
Stage 5: is a special stage called REM sleep which stands for Rapid Eye Movement.
This is because the eyes begin to move underneath our eyelids. This is also the
stage where we have most of our dreams and some say that our eyes move at this
stage as we are following the images in our minds.
Deep sleep helps our bodies recover and REM sleep helps our mind recover. So
lack of REM and Deep sleep can badly affect us during the day. Below is a graph
measuring the sleep of a normal adult.
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5 Bad Habits of Sleep Colin Espie who is a Professor at Glasgow University is an expert in sleep and has
done a lot of research into how to help people with sleep problems. In his work he
found that there are 5 bad habits that can impact on our sleep, they are: Caffeine,
Nicotine, Alcohol, Diet and Exercise.
1. Caffeine
Caffeine is a stimulant which means it can keep us awake which is found in tea,
coffee, chocolate and most fizzy drinks and energy drinks.
Research suggests that we should avoid having caffeine 4 hours before we go to
bed. You can always substitute decaf products if you enjoy a hot drink in the
evening.
The recommended daily average intake of caffeine is 300mg. There is
approximately 100mg of caffeine in a cup of coffee and 75mg in a cup of tea. So you
can see that in one day it is recommended that we only have 3 cups of coffee or 4
cups of tea.
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2. Nicotine
Nicotine is also a stimulant and has a similar effect to caffeine so it is thought
smokers should avoid smoking an hour before bed.
Similarly try not to smoke if you wake up in the night as this will only disturb you
getting back to sleep and might cause your body to start to wake itself up during the
night craving a cigarette.
3. Alcohol
It is a common myth that alcohol is good for our sleep. It is true that alcohol can help
us get off to sleep at first because it is a depressant so it can have a sedative effect.
However it disrupts our sleep during the night as it goes through our bodies and the
effect wears off. We wake up, need a drink of water, need the toilet etc. The next
morning you might also feel the effects (hangover).
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4. Diet
Try not to eat a large meal right before bed. Eating a large meal late at night can
keep us awake as our bodies are awake digesting our food. Some people find that
eating a small snack at bedtime though is helpful (e.g. toast).
5. Exercise
Exercise does help us release stress and worry and so being active can then help us
sleep at night. However, straight after exercising we can feel energized as our body
releases endorphins that make us feel good. So exercising during the day can be
helpful but not in the 2 hours before bed.
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Bedroom Factors
Espie also found in his research that our bedrooms can have a big impact on how
well we sleep stating that the 4 most common problems are: Noise, Light, Comfort
and Temperature.
Noise
We all know that noise when we are trying to sleep can be disruptive and annoying.
In addition those with insomnia are also thought to be more sensitive to noise so
having a quiet place to sleep is important. Sometimes we might not be able to
control the level of noise for example, a busy street outside, but there are some
things we can do – close windows, use ear plugs or perhaps move rooms to a
quieter part of the house.
Light/Dark
• Maximize light in the day minimize in the night.
• Melatonin occurs naturally in our bodies and makes us feel sleepy. Because
we only want to feel sleepy at night melatonin responds to darkness and is
only produced when it gets dark. So during the day no melatonin is produced
but at night, as it gets dark melatonin is switched on, released into our
bloodstream and makes us feel tired. Lasts for about 12 hours and then it
stops as daylight comes back.
• So, being outside or in daylight will help keep you awake and then having a
darkened room will help you sleep.
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Comfort
• Things like keeping your room tidy and un-cluttered can make it feel more
relaxing. Even little things like making your bed in the morning can make it
seem like a much nicer place.
• For example, having to move clothes, books or furniture to be able to get into
bed at night isn’t going to make going to bed a calm and peaceful experience.
• If you’re thinking of decorating your bedroom studies have shown calmer,
more neutral shades are better for sleep and blue and green are the most
tranquil colours.
Temperature
You want to make sure your room is a good temperature for you – there is no ideal
temperature but studies have shown rooms over 24°C are associated with reduced
deep sleep and increased night-time waking. Meanwhile rooms less than 12°C are
associated with unpleasant and emotional dreams.
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5 Good Habits of Sleep
• Having a bedtime routine
• Reduce napping
• Try to use your bedroom for mainly sleep
• Only go to bed when sleepy
• 20 minute rule.
Bed Time Routine
• Approximately an hour before bed it is a good idea to use the time to relax
and unwind after the day and prepare for going to sleep. It’s time for you to
have a bit of peace and quiet and do something you find enjoyable but also
relaxing. Doing so creates a space to wind-down and get in the right frame of
mind for bed.
• It is important to find somewhere to do this other than the bedroom to
maintain the association between your bedroom and sleep.
Reduce Napping
• For people with insomnia napping during the day can make it more difficult to
get to sleep at night and reduce the quality of the sleep you do get.
• Obviously for those with long-term insomnia it might be that you feel you have
to nap during the day in order to make it through and that is perfectly fine.
However if you do want to try and reduce your napping
• One technique is to keep your nap to a maximum of 40 minutes and before
3pm in the afternoon. Perhaps set an alarm on your phone or clock to wake
you before your sleep gets too deep.
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Bedroom for Sleep Only
• Creating a good association between your bedroom and sleep is essential so
it’s important to try and use your bedroom just for sleeping, that means
watching TV, playing games, using the computer or eating should be done in
another room so that when you go to bed you associate it with sleeping rather
than other activities that are associated with being awake and make us feel
awake. This way, when we go to bed we will be expecting to go to sleep and
not do any other activities.
• Some people do find that watching TV or playing games in bed does help
them sleep but usually these are not people who struggle with sleep, but it is
always what works best for you.
Sleep Vs Tired
There’s a difference between being tired and being sleepy. Tiredness is a feeling of
exhaustion and doesn’t necessarily involve the desire to sleep. Sleepiness however
is a desire to sleep and wanting to go to sleep. Waiting until we are sleepy to go to
bed can help us go to sleep faster and going to bed too early gives us more time to
worry which only keeps us awake.
The 20 Minute Rule
The 20 minute rule says that if you find you are unable to fall asleep after about 20
minutes, get out of bed and find something else to do in another room. There is no
need to watch the clock but after 20-30 minutes has passed get up, leave the room
and find a quiet activity to do. Only then return to bed when you feel sleepy again.
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Coping Strategies to Sleep
Safe Place Imagery
This involves creating a story in your mind of somewhere you love. You want to
imagine yourself in a place that you feel happy, safe, relaxed and at ease – it is just
yours – your own safe place you can go in your mind. It could be a holiday
destination, your favorite place, a place you’ve always dreamed of going or even
create a new place in your imagination!
Putting the Day to Rest
Often at night we can spend time thinking about the day just gone or what’s
happening the next day. Maybe its things to remember, things you’ve forgotten or
places you have to be. Whatever it is it can help to set aside 20 minutes in the
evening to think about the day. Use a pad to write down anything that you need to
and then when you go to bed you can remind yourself that you have dealt with
everything and it is sorted.
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Sleep Diary
A good way to establish a better sleeping routine is to keep a Sleep Diary. Fill out
this diary in the mornings answering the various questions about last night’s sleep.
Don’t worry about getting everything exact, estimates will do.
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Looking after yourself in the future
The focus of the last section of this booklet is all about remaining well, maintaining
the progress you have made so far and learning new ways to prevent relapse.
It is important to note the difference between a Lapse and a Relapse.
A lapse is a brief return in symptoms of feeling down or anxious and a brief pause in
your new behaviours. It is very normal for this to happen and it usually lasts a few
days. If we lapse back into old ways of doing things, it does not mean we have gone
back to square one! Be compassionate to yourself and start practicing your skills
again.
If the symptoms and old behaviours were to return over a longer period of time, start
to spiral and make you feel worse, then we would consider this a relapse. A relapse
is NOT a total failure and is all part of learning to cope with Anxiety and Depression
long term.
The first step in preventing relapse is identifying and recognising your early warning
signs, or red flags. Early warning signs are signs/symptoms which can easily go
unnoticed and unchecked. They do not indicate that you are severely depressed
and/or anxious, but they are a sign that things could go that way if left unchecked.
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Management Plan
Task: Think about your early warning signs and make a note of them – what do they
look like? How will you recognise them? How does your behaviour change?
Then think about a management plan for each early warning sign – think of sources of
support, what can you do to help yourself?
Early Warning Signs
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Wellbeing Action Plan…
Check list on how you are doing to help you review your mood and anxiety level, and to review your red flags. Check whether you have used old behaviours or stopped doing things. Decide if you need to revise your skills and make a plan to start doing them again. If things are going well, then review what is working for you:
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Keys to success in overcoming anxiety/low mood
Here are just a few tips for you to remember:
Be patient.
Take small, gradual steps!
Gradual, non-pressured, but consistent progress is the way
to go.
Recognise your improvements, small as they might be at
first, and give yourself credit
Setbacks are unavoidable, so accept them as an integral
part of the recovery process.
Using this approach assures you of significant improvement
on your way towards complete recovery.
Remember, the past does not equal the future.
Well Done!
